Provider Demographics
NPI:1942808670
Name:ANDERSON, REBECCA LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:BECCA
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1495 S TECH LN APT A203
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8209
Mailing Address - Country:US
Mailing Address - Phone:208-971-5397
Mailing Address - Fax:
Practice Address - Street 1:730 W USTICK RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5941
Practice Address - Country:US
Practice Address - Phone:208-971-5397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-3441225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist